Dear all,
A solid research month in tendinopathy. The most pleasing thing is there is a lot more research on rehabilitation. Here are some highlights.
Rees et al. argue for inflammatory vs degenerative pathoaetiology in tendinopathy. An interesting read highlighting that there are inflammatory cells and biochemicals in tendinopathy and arguing for the use of some well known and less known anti-inflammatory agents in some presentations. The key for me is irritable/angry pain, which we treat like an inflammatory issue, although we can never be completely sure of pain mechanisms in the clinic.
The VISA questionnaire has another family member! Cacchio et al. have developed and validated the VISA-H, for hamstring tendinopathy. Worth a look and try.
Malliaras et al. have reviewed loading programs in Achilles and patellar tendinopathy. The take him message is – load is good! Eccentric loading is not clearly better when compared to other loading forms when considering both clinical and mechanistic outcomes (although there is limited good quality evidence). We suggest that concentric-eccentric may be better for people with concentric deficits, heavy load may be better to adapt tendon. We also argue for isometric load – great for tendons – more on this at some point.
Chris Littlewood has been busy! Littlewood et al. have described a progressive and resisted shoulder rehabilitation program. The critical part is coupling the program with sound education re pain that minimizes fear avoidance, incorrect beliefs about the pathology, and sets expectations, instills confidence and empowers the patient to self manage – in my view this is equal and sometimes more important than the actual intervention in all types of rehabilitation.
Littlewood et al. reviewed the effectiveness of conservative intervention for ‘rotator cuff tendinopathy’ – a clinical diagnosis of shoulder impingement syndrome (SIS) symptoms. They found exercise is superior to placebo and no treatment, and multimodal physio or surgery did not add benefit over exercise alone. Most other things have conflicting / no evidence to support – eg steroid injections, manual therapy, shockwave, etc. So very positive review for exercise, in no doubt a broad spectrum of SIS associated pathologies. A key point is that only mechanical shoulder pain was included, which would have maximized the positive exercise findings. So get your shoulder patients into stable pain and then load them progressively!
Klauser et al. have described mainly the imaging features of greater trochanteric pain syndrome. They confirm the clinical consensus that tendon pathology is much more common than bursitis. Is the bursa a secondary pathology in most cases?
Jandacka et al. show increased ankle dorsiflexion at heel strike, reduced ankle power and increased ground reaction force on the affected side 4 years after Achilles rupture repair followed by rehab and running retraining. Running performance and pain were ok, but obviously the proximal and opposite kinetic chain are at risk given the continued local functional deficits after the Achilles repair. Assuming rehab was adequate, it may be the lengthening of the Achilles tendon post rupture that limits functional restoration of that kinetic chain segment.
Here is a link to the abstracts: Tendinopathy research blog march
